The Broken System - #4: Who Am I Working For?

Since I am self-employed (as part of a partnership), the easy answer would be to say I work for myself. That is not, however, what was meant by the question (and it would make a dull blog post if it was); the intent of the question was this: for whose interest am I most working for? Who am I trying to please? Who is my boss?

My answer? I have many bosses:

My patients

The insurance companies

My patients' employers

Our business

The government

Oprah

So who really is my boss?

We all, in the end, work for Oprah. That's a given. I won't add any more to that as it is self-evident.

Being a primary care doctor, I would like to say that I work for my patients. I would like to say that the only thing that matters is the health and happiness of the people in my care; but that would not be true. I fight to keep this focus in my office, but sadly it's still not the reality I live. The reality I live is that of a planet being torn out of its orbit by larger, more powerful celestial bodies, all trying to make themselves the center of my universe.

Who is my boss?

Insurance Companies?

They certainly write a big chunk of my paycheck, commanding an increasing amount of my time. I have contracts with insurance companies, agreeing to what they pay. I follow rules of insurance companies to get the patients the care they need and what the insurers dictate, (which are sometimes at odds). Insurance companies have more access to patient records than patients do, or at least they have easier access. Insurance companies can decide if they will pay me or not, while the patient doesn't have that option.

Clearly, the pull of the insurers' gravity is stronger than that of the patient. Clearly my patients are not my real boss.

Employers?

But who writes the check for the insurance companies? Employers do. Employers dictate just how strict of rules the insurance companies will keep me under. When they choose an insurance plan for their employees, employers dictate how much I can charge at each visit, what services I offer will be covered, what payment structure I will receive (capitated, fee-for-service, or high-deductible). Much of what I can or cannot do is dependent on this decision.

If you asked employers, however, they would tell you that they are "at the mercy" of the insurance companies. Despite the fact that the employer is writing a check to the insurer, the relationship is hardly one of control on the part of the employer. As owner of a my own business I can attest to the one-sided nature of my relationship with my employees' insurance carrier.

So what about my business? Is my practice my boss? Since I am a part-owner of my business, it is not quite as clear as it would be for physicians employed by a practice or hospital. But the reality is the same in many ways. My practice decides what contracts we will accept or reject. It tells me if I am seeing enough patients, dictating how much time I am spending on each patient. The practice pays for the medical record system, tells me when I can have time off and, in extreme cases, could fire me. I certainly feel like a factory worker at times, punching in at the start of a long day with a conveyor belt of patients coming in so I can make money for "the man."

But who am I fooling? Our practice is also totally dependent on insurers, going to great lengths to make what I do come out in a format that will please insurers enough to pay us. Our practice could go broke should the government go through with its threatened cut to Medicare reimbursement. We are a service industry, totally at the mercy of our "customers," or "clients." Our business is but a pass-through vehicle for me to be paid by insurers and a front to let me see patients.

I work at my practice, but not for my practice. My practice is not my boss.

The Government?

A significant percentage of my patients are either Medicare or Medicaid, so a large chunk of my paycheck comes from the government. Many of the contracts I get from private insurers are based on a percentage of Medicare's rates, so the government is a very powerful force in determining what I get paid. In addition, while I can opt out of any insurance plan if I don't like the rates, and have the option of negotiating a better rate, dropping out of government contracts is much, much harder. There is also no chance for negotiation; I either take what they offer or don't have their patients.

In addition:

The government set up our procedure-driven model of care that has so favored the specialist over primary care.

They pay for enormous hospital bills but not (up until very recently) for me to prevent those enormous hospital bills.

The government sets the rules for documentation - those rules that force me to put so much meaningless information into the record that I can't find the useful information I need.

The government says that I can't send many kinds or e-prescriptions, even though doing so would be more secure and less prone to abuse.

The government sets malpractice laws that favor the accuser and so makes my nurses quick to send people to the ER unnecessarily and makes me increase my test-ordering and documentation to avoid litigation.

The government doesn't just tell me to get on electronic medical records (which I had already done), but gives me a large number of hoops I must jump through to prove that I am using them "meaningfully."

The government promises to make those rules more invasive and onerous as time progresses.

The government is supposed to regulate the insurance carriers, drug companies, and device manufacturers, many of whom are making huge profits during a time of economic crisis. They "regulate" the drug industry, letting companies gouge with generic drugs, set prices inordinately high, and advertise directly to patients information that tricks them into believing things that aren't proven or that are patently false.

The government does nothing while more and more people outside the doctor-patient relationship plunge onto the system and plunder it for what they can get.

In short, the government stands watch while the health care system crashes and burns, the end result of which is that my patients are able to afford less and less care and I am too busy dealing with pleasing the system to give them the attention they deserve.

So who am I working for? The one for whom the system is designed, the patient, is not just competing for my attention but is on the periphery looking in while I deal with these other entities. The patient waits for an hour while I see extra patients and document profusely. The patient can't afford prescriptions I write because the cost of drugs is too high or the drugs are denied due to insurance formularies. The patient is afraid of me making a diagnosis for fear of losing their insurance. The patient pays more and gets less. I work harder and get less.

Who am I working for? Far too many people who are making it far too hard to do my job.

I wonder what care would look like if I actually did work for my patients? What would real care, not care that is torn apart by competing gravitational forces, be? What would the chart look like? How long would the visits last? How much would the visit cost, and how much would drugs cost?

What would care look like if the patient was really who I was working for?